Abstract
Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the English language. Eleven studies were identified on the frequency of medication errors in the NICU. The highest rate was 5.5 medication errors per 100 prescriptions; however, medication error rates varied widely between studies, partly due to differences in the definition of an error and the rigor of the method used to identify medication errors. Furthermore, studies were difficult to compare because medication error rates were calculated differently. Most studies did not assess the potential clinical impact of the errors. The majority of studies identified dose errors as the most common type of error. Computerised physician order entry and interventions by clinical pharmacists (e.g. the participation of pharmacists in ward rounds and review of patients’ prescriptions prior to dispensing) were the most common interventions suggested to improve medication safety in the NICU. However, only very limited data were available on evaluation of the effects of such interventions in NICUs. More research is needed to determine the frequency and types of medication errors in NICUs and to develop evidence-based interventions to improve medication safety in the NICU setting. Some of these research efforts need to be directed to the establishment of clear definitions of medication errors and agreement on the methods that should be used to measure medication error rates and their potential clinical impact.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Kunac DL, Reith DM. Identification of priorities for medication safety in neonatal intensive care. Drug Saf 2005; 28(3): 251–61
Morselli PL. Clincial pharmacokinetics in neonates. Clin Pharmacokinet 1976; 1(2): 81–98
Aranda JV, Portuguez-Malavasi A, Collinge JM, et al. Epidemiology of adverse drug reactions in the newborn. Dev Pharmacol Ther 1982; 5(3–4): 173–84
Koren G. Therapeutic drug monitoring principles in the neonate. Clin Chem 1997; 43(1): 222–7
Conroy S, Mclntyre J. The use of unlicensed and off-label medicines in the neonate. Semin Fetal Neonatal Med 2005 Apr; 10(2): 115–22
Conroy S, Mclntyre J, Choonara I. Unlicensed and off label drug use in neonates. Arch Dis Child Fetal Neonatal Ed 1999 Mar; 80(2): F142–4
Celeste HP. Therapeutic drug monitoring in neonates. Neonatal Network 1995; 14(2): 21–6
Rakhmanina NY, van den Anker JN. Pharmacological research in pediatrics: from neonates to adolescents. Adv Drug Deliv Rev 2006 Apr 20; 58(1): 4–14
McClead Jr RE, Menke JA. Neonatal iatrogenesis. Adv Pediatr 1987; 34: 335–56
O’Donnell CP, Stone RJ, Morley CJ. Unlicensed and off-label drug use in an Australian neonatal intensive care unit. Pediatrics 2002 Nov; 110(5): e52
Barr J, Brenner-Zada G, Heiman E, et al. Unlicensed and off-label medication use in a neonatal intensive care unit: a prospective study. Am J Perinatol 2002 Feb; 19(2): 67–72
Anderson BJ, Ellis JF. Common errors of drug administration in infants: causes and avoidance. Paediatr Drugs 1999 Apr; 1(2): 93–107
Gray JE, Goldmann DA. Medication errors in the neonatal intensive care unit: special patients, unique issues. Arch Dis Child Fetal Neonatal Ed 2004 Nov; 89(6): F472–3
Mclntyre J, Choonara I. Drug toxicity in the neonate. Biol Neonate 2004; 86(4): 218–21
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 Apr 25; 285(16): 2114–20
Simpson JH, Lynch R, Grant J, et al. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004 Nov; 89(6): F480–2
Vincer MJ, Murray JM, Yuill A, et al. Drug errors and incidents in a neonatal intensive care unit: a quality assurance activity. Am J Dis Child 1989 Jun; 143(6): 737–40
Myers TF, Venable HH, Hansen JA. Computer-enhanced neonatology practice evolution in an academic medical center. NICU Clinical Effectiveness Task Force. J Perinatol 1998 Nov; 18 (6 Pt 2 Su): S38–44
Larsen GY, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics 2005 Jul; 116(1): e21–5
Carroll AE, Tarczy-Hornoch P, O’Reilly E, et al. Resident documentation discrepancies in a neonatal intensive care unit. Pediatrics 2003 May; 111 (5 Pt 1): 976–80
Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet 1989 Aug 12; 2(8659): 374–6
Suresh G, Horbar JD, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004 Jun; 113(6): 1609–18
Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000 Dec; 83(6): 492–7
Chappell K, Newman C. Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal Neonatal Ed 2004 Nov; 89(6): F483–4
Cordero L, Kuehn L, Kumar RR, et al. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J Perinatol 2004 Feb; 24(2): 88–93
Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics 1986 Jun; 77(6): 848–9
Lucas AJ. Improving medication safety in a neonatal intensive care unit. Am J Health Syst Pharm 2004 Jan 1; 61(1): 33–7 513
Blum KV, Abel SR, Urbanski CJ, et al. Medication error prevention by pharmacists. Am J Hosp Pharm 1988 Sep; 45(9): 1902–3
Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics 1987 May; 79(5): 718–22
Condren ME, Haase MR, Luedtke SA, et al. Clinical activities of an academic pediatric pharmacy team. Ann Pharmacother 2004 Apr; 38(4): 574–8
Krupicka MI, Bratton SL, Sonnenthal K, et al. Impact of a pediatric clinical pharmacist in the pediatric intensive care unit. Crit Care Med 2002 Apr; 30(4): 919–21
Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skillednursing facilities. Am J Health Syst Pharm 2002 Mar 1; 59(5): 436–46
Wong IC, Ghaleb MA, Franklin BD, et al. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Saf 2004; 27(9): 661–70
Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998 Oct 21; 280(15): 1311–6
Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999 Jul; 6(4): 313–21
Potts AL, Barr FE, Gregory DF, et al. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 2004 Jan; 113 (1 Pt 1): 59–63
King WJ, Paice N, Rangrej J, et al. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003 Sep; 112 (3 Pt 1): 506–9
Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med 2001 Sep; 155(9): 1002–7
Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003 Apr; 111 (4 Pt 1): 722–9
Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005 Dec; 116(6): 1506–12
Copelan D, Appel J. Implementation of an enteral nutrition and medication administration system utilizing oral syringes in the NICU. Neonatal Netw 2006 Jan; 25(1): 21–4
Zenk KE. How you can serve as pharmacist to the neonate. Pharm Times 1980 Nov; 46(11): 40–9
Johnson FL, Winship III HW, Trinca CE, et al. Neonatal medication surveillance by the pharmacist. Am J Hosp Pharm 1977 Jun; 34(6): 609–12
Khoo GP, Bolton O. Neonatal and paediatric intensive care. Hospital Pharmacist 2003 Feb; 10: 66–71
Poley MJ, Bouwmans CA, Hanff LM, et al. Efficiency of different systems for medication distribution in an academic children’s hospital in The Netherlands. Pharm World Sci 2004 Apr; 26(2): 83–9
Fontan JE, Maneglier V, Nguyen VX, et al. Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci 2003 Jun; 25(3): 112–7
Dean B, Schachter M, Vincent C, et al. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002 Apr 20; 359(9315): 1373–8
Schneider MP, Cotting J, Pannatier A. Evaluation of nurses’ errors associated in the preparation and administration of medication in a pediatric intensive care unit. Pharm World Sci 1998 Aug; 20(4): 178–82
Acknowledgements
No sources of funding were used in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chedoe, I., Molendijk, H.A., Dittrich, S.T.A.M. et al. Incidence and Nature of Medication Errors in Neonatal Intensive Care with Strategies to Improve Safety. Drug-Safety 30, 503–513 (2007). https://doi.org/10.2165/00002018-200730060-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00002018-200730060-00004